Female Infertility

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Female Infertility

Underlying causes of female infertility may vary significantly.

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Most common causes of female infertility include menstruation-related and ovulatory disorders, endometriosis, polycystic ovary syndrome, premature menopause, obstructed tubes and structural disorders of female organs. Many other etiologies can also be identified. Idiopathic (unexplained) infertility is also the case.

Etiologies of Female Infertility;

Ovulatory Disorder:

It is the most common cause of female infertility and means either anovulation or irregular/infrequent ovulation. At normal conditions, one of non-matured eggs in ovary matures and hatches every month and thus, ovulation occurs.

Anovulation means that there is no ovulation. Anovulation is the most important reason of menstruation disorder and infertility. Ovulation might not occur although the woman is menstruating. Hypomenorrhea or amenorrhea usually points out an ovulatory disorder. However, ovulatory disorders can be accompanied by regular menstruation.

Ovulatory disorders can be examined in four principal groups: 

Deficiency of hormones which stimulate ovary.

Cases with polycystic ovary syndrome (PCOS). 

In addition to hypomenorrhea or infrequent menstruation, skin changes (hirsutism, oily skin and acne), characterized with abnormally high levels of androgen, are also seen in women.

They are patients with premature menopause. In such patients, any and all egg-stimulating medicines and protocols fail, including in vitro fertilization. However, ovarian function may restore in first 5 years in a part of women (10%) with premature menopause. It is not clear to predict when this restoration will occur in which women, how long it will take and whether it will be associated with ovulation or not.

It is characterized with hyperprolactinemia, excessive secretion of a hormone that induces production and release of milk. Ovulation does not occur when prolactin level is above normal limits. Ovulation is restored in most women with a medicine that reduces level of prolactin hormone.

Damaged or Occluded Tubes:

Partial or total obstruction of tubes hinder union of sperm with ovum in the tube, and thus, fertilization and subsequent conception will be impossible. Infertility can be secondary to adhesion, which can disrupt anatomic relations of bilateral tubes and ovaries, due to a reason whatsoever. Adhesion can arise out of previous tube infections, endometriosis or prior postoperative intra-abdominal adhesions. Sexually transmitted infections are one of the most important cause of the tubal damage in developed countries.

Intra-uterine Adhesions:

Intra-uterine adhesions may be the underlying cause of the infertility. Previous curettage and uterine surgeries may also lead to intra-uterine adhesions.

It is very important to verify, with imaging modality, that intrauterine cavity is intact, before IVF therapy is started; so evaluation is often made with Hysterosalpingography or sometimes with Hysteroscopy. Hysteroscopy enables concomitant correction of abnormal conditions (intra-uterine adhesion, polyp, myoma or congenital septum).

Intrauterine polyps can also cause infertility. Polyps are small benign tissue formations, similar to moles. They are not related to a malignant condition, but they may sometimes hinder the conception. They can be treated with minor surgery.

Cervical Factor:

Deformities, infections, bad mucus quality and polyps are some of cervical problems that result with female infertility. Secretion of cervix varies by amount and consistency due to the effect of hormones at different stages of menstruation. Mucus can vary by quantity and quality in menstruation cycles with the effect of estrogen and progesterone hormones. Bad mucus quality can prevent the sperm to progress into the female reproductive system.

Endometriosis:

Endometriosis implies presence of interior lining of uterus at extra-uterine localization. These foci at abnormal localizations may lead to adhesions and ovulatory disorders over time. Seventy percent of patients with endometriosis suffer from infertility problem. Endometriosis is sensitive to hormones and bleeds during menstruation, similar to tissue which is lining the uterine cavity. These intra-abdominal bleedings result in adhesions over the time. Laparoscopy is used for diagnosis. Laparoscopy is a surgical procedure that enables the visualization of internal organs and the treatment, if possible. Endometriosis in ovaries leads to development of cyst. These cysts are called endometrioma or colloquially “Chocolate Cysts”. These cysts can lead to serious ovulation problems and need to be treated.

Reasons Related to Immunity System:

There are limited options for treatment of immunological etiologies. Antibodies, which kill or immobilize sperms, can be found in cervical secretion, on sperm surface, in sperm or in three of them. Cervical mucus of the female subject, sperm specimen of the male subject and blood samples of both male and female subjects can be analyzed to determine these antibodies.

Idiopathic Infertility:

This term implies all infertility conditions, of which etiology cannot be identified with modern diagnostic methods. All tests are within normal limits in approximately 15% of the so-called infertile couples. Hypotheses include disorders of sperm that cannot be identified with tests and some problems related to hatching and motions in Fallopian tubes. It is also known that psychological factors and stress may also exert negative effects on the hormone balance. Pregnancy can be achieved with sexual intercourse, if stress can be eliminated.

Age of Woman:

Frequency of ovulation and maturation of quality ovum decrease with increasing age of women. Chance of pregnancy gradually decreases especially for women above the age 35. Although menstrual cycle is usually normal after the age 40, chance of pregnancy decreases below 10%. Even if eggs maturate and ovulation occurs, the chance of egg to be fertilized decreases substantially.


Male factors accounts for approximately 40% of infertile couples. In the management of male infertility, a rapid advancement is made thanks to techniques that are applied in the last 7 to 8 years. Although male infertility is mostly diagnosed with a spermiogram, special examinations may be required in some special conditions.

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